Medical and Paediatric Oncology

Oncoradiology preparedness in the COVID-19 pandemic: Perspective from a tertiary oncology referral center from Eastern India Argha Chatterjee, Bivas K Biswas, Anisha Gehani, Jayanta Das, Saugata Sen, Sumit Mukhopadhyay, Aditi Chandra, Priya Ghosh, Bharat Gupta, Dayanand Lingegowda Indian Journal of Medical and Paediatric Oncology 2020 41(6):789-798 At the time of writing this article, more than 18 million people worldwide have been infected by the severe acute respiratory syndrome-associated coronavirus-2 and about 700,000 people have died from coronavirus disease 2019 (COVID-19). In India, about 190,000 people have been infected and nearly 39,000 people have succumbed to this infection. Infection among health-care workers has emerged as one of the key problems in facing this pandemic. The purpose of this article is to describe the measures taken by the department of oncoradiology at our institution to control the infection and minimize staff exposure during the current lockdown period with reduced patient load and in the post-lockdown period with increased demand for radiology services. The key focus of this article is the continued delivery of cancer imaging services with practical precautions and optimized resources. We have also discussed algorithms and protocols unique to the practice of oncoradiology in the time of the COVID-19 pandemic.

Clinical research in hematology-oncology in India during the COVID-19 era Nishant Jindal, Pankaj Malhotra, Amol N Patil, Deepesh P Lad Indian Journal of Medical and Paediatric Oncology 2020 41(6):799-800

Immunotherapy in rare cancers Venkata Pradeep Babu Koyyala, Padmaj Kulkarni Indian Journal of Medical and Paediatric Oncology 2020 41(6):801-803

Multidisciplinary joint clinics: Talent wins games, but teamwork wins championships Rima Sanjay Pathak, TS Shylasree, Jyoti Bajpai Indian Journal of Medical and Paediatric Oncology 2020 41(6):804-808 Cancer is among the leading causes of deaths worldwide. The treatments of cancer across most sites involve using surgery, systemic therapy, and radiation therapy. The treatment protocols are complex and require careful planning at the beginning of the therapy and coordination between the treating teams, the patient, and the caregivers to ensure compliance and avoid unnecessary treatment delays. This commentary provides an insight into the role the multidisciplinary joint clinics play in providing personalized cancer care. While such joint clinics are advantageous, they are not devoid of drawbacks and these are also enumerated. In this era, when communication platforms are increasingly digitized, we have highlighted the need for virtual tumor boards. The commentary aims to motivate the development of multidisciplinary joint clinics for ensuring holistic cancer care across the country.

Gastrointestinal stromal tumor – An overview Anant Ramaswamy, Vikram Chaudhari, Prabhat Bhargava, Manish Bhandare, Rajiv Kumar, Shailesh V Shrikhande, Vikas Ostwal Indian Journal of Medical and Paediatric Oncology 2020 41(6):809-818 Gastrointestinal stromal tumors (GISTs) are rare tumors but are most common mesenchymal tumors of the digestive tract. They are commonly seen in the stomach (60%) and small intestine (30%). GISTs are likely derived from the interstitial cells of Cajal or their stem cell precursors. They are best characterized by computerized tomography and have a specific staining pattern on immunohistochemistry, i.e., C-Kit and DOG-1. The treatment of GIST is based on the risk assessment for relapse, and patients with localized GIST require resection with or without adjuvant imatinib mesylate (IM). Advanced unresectable tumors are usually treated with IM, with a number of further options available for patients post progression on IM. There is an increasing emphasis on identifying C-Kit and platelet-derived growth factor receptor alpha mutations in all patients with GIST, as these are driver mutations with current and future therapeutic implications.

Efficacy of antiemetic regimens for prevention and treatment of chemotherapy-induced nausea and vomiting in patients of breast cancer receiving highly emetogenic chemotherapy Soumya Vij, Dilip Chander Dhasmana, Suman Bala, Sanjiv Kumar Verma Indian Journal of Medical and Paediatric Oncology 2020 41(6):819-824 Background: Chemotherapy is fraught with serious and troublesome adverse effects, of which nausea and vomiting appears earliest and is the most disturbing. Therefore, this study was planned to investigate the antiemetic drug regimens used for chemotherapy-induced nausea vomiting (CINV) in patients with breast cancer receiving highly emetogenic chemotherapy (HEC). Subjects and Methods: An observational follow-up study was conducted to assess the efficacy of antiemetic regimens in breast cancer patients receiving HEC. A total of 71 newly diagnosed patients with breast cancer were included in the study. Patients were assessed for nausea by the visual analog scale, and a history of emetic episodes and need for rescue medication were recorded at 0 h, 6 h, 24 h, 48 h, and 120 h post-chemotherapy till three cycles. Results: The patients were prescribed a combination of ondansetron and dexamethasone (n = 23, n = 17, and n = 13 in first, second, and third cycle, respectively) or a combination of aprepitant, ondansetron, and dexamethasone (n = 48, n = 54 and n = 56 in the first, second, and third cycle, respectively). The intensity of nausea was higher for the patients who were prescribed ondansetron and dexamethasone regimen as compared to patients prescribed aprepitant additionally. Complete response, i.e., no emesis and no rescue medication, was higher in triple-drug regimen (52% vs. 0.4%, 63% vs. 17.6%, and 69% vs. 23% in three cycles, respectively). Conclusion: The control of CINV was better with a combination of aprepitant, ondansetron, and dexamethasone as compared to a regimen without aprepitant.

Patient-reported shoulder morbidity and fatigue among breast cancer survivors: An insight from a tertiary care cancer hospital Abhishek Basu, Janmenjoy Mondal, Bhukya Swetha, Shinjini Chakrabarty, Debjit Ghosh, Subhendu Gangopadhyay, Bidyut Mandal Indian Journal of Medical and Paediatric Oncology 2020 41(6):825-831 Context: Breast cancer is the most common cancer in Indian women with an annual mortality of around 87,000. Treatment for breast carcinoma may lead to swelling of the ipsilateral arm, shoulder stiffness, arm pain, and cancer-related fatigue. Very few centers in India have reported the arm and shoulder morbidity treated in their hospitals. Aims: The aim was to evaluate the predictive factors of arm and shoulder morbidity and fatigue among breast cancer survivors. Settings and Design: This was a retrospective analysis based on a prospectively maintained database. Materials and Methods: Early and locally advanced cases of breast cancer patients were screened for the study during 2015–2018. Eligible participants were invited to fill up the predetermined questionnaire, and their demographic and treatment-related information was accrued from a file archive. Follow-up period was estimated from the date of tissue diagnosis to last contact/time of interview. Results: Shoulder stiffness was the most common complaint followed by arm numbness. Obesity and diabetes played a crucial role in most of the morbidities and fatigue. The median fatigue score was 34, and the median time of appearance of lymphedema was 13 months. Modified radical mastectomy and radiotherapy to axilla were statistically significantly (P = 0.04 and 0.01, respectively) associated with greater shoulder stiffness and arm swelling. Conclusions: Obesity, diabetes, type of surgery, the extent of axillary dissection, and radiation plan are the major predictive factors of arm and shoulder morbidity. Further prospective validation is necessary for future breast cancer survivorship programs.

Does neoadjuvant chemotherapy increase the survival in patients with locally advanced gastric cancer patients? – A real-world evidence Murugesan Janarthinakani, Selvaraj Kalaiselvi, Rajamani Priyadarshini, Seshachalam Arun, K Shashidhar, R Krishnakumar, N Manjunath, Sirigeri Roopa, SG Raman Indian Journal of Medical and Paediatric Oncology 2020 41(6):832-840 Background: In locally advanced gastric cancer (LAGC), perioperative chemotherapy has shown to improve the survival to a larger extent compared to surgery alone. In India, the treatment followed for gastric carcinoma widely varies based on the type of health-care provider and treatment access. There is a paucity of data on the role of neoadjuvant chemotherapy on survival among LAGC patients in the Indian context. Aim: The aim of this study was to compare the disease-free survival (DFS) and overall survival (OS) between neoadjuvant and adjuvant chemotherapies among LAGC patients. Subjects and Methods: This was a retrospective cohort study involving clinical record review of LAGC patients enrolled between 2015 and 2017 from four tertiary cancer centers in South India. The date for the following events, namely diagnosis, recurrence, death, and last day of visit, was extracted in a mobile-based open-access tool. The median duration of OS and DFS between the neoadjuvant and adjuvant groups was compared using Kaplan–Meier survival curves. Results: Of the 137 patients, 70 (51%) had received neoadjuvant chemotherapy followed by surgery and 67 (49%) had adjuvant chemotherapy following the surgery. The mean (standard deviation) age of participants was 55.4 (11.4) years. Seventy-eight percent of the patients were diagnosed at Stage 3 or 4. Regional lymph nodes were involved in 83.9%. The median duration of follow-up was 15 months. The OS in the neoadjuvant and adjuvant groups was 18.6 months and 8.3 months, respectively. Nonregional lymph node involvement and adjacent organ involvement had independently increased the risk of death. Conclusion: Among LAGC patients, the neoadjuvant chemotherapy indicated a better median and DFS compared to the adjuvant group. However, these findings were statistically not significant. The current study has contributed an important finding to the existing evidences of clinical practice in an Indian setting. Further large-scale studies are required to validate the promising trend of using neoadjuvant chemotherapy in LAGC.

Treating acute myeloid leukemia among children with down syndrome Rajan Kapoor, Karthik Ram Mohan, Shuvendu Roy, Suman Kumar Pramanik, Sanjeev Khera, AK Simalti Indian Journal of Medical and Paediatric Oncology 2020 41(6):841-845 Background: Down Syndrome (DS) children with acute myeloid leukemia (AML) have unique differences in clinical features, epidemiologic nature, and biologic patterns of disease compared with AML in children without DS. Aims and Objective: AML in DS children should be considered distinct disorder from AML in Non DS population and treatment needs to be customized for this population. In this retrospective study spanning from 2014 to 2019 we present our experience of managing leukemia in children with DS. Materials and Methods: From 2014 and 2019, 72 children aged below 18 years were managed at our institute with acute myeloid leukemia (AML). Out of these 72 children with AML, 7 children were with DS which was confirmed by karyotyping. Majority of these children had M7 while M2 and M4 subtypes were seen in one child each. On conventional karyotyping in addition to trisomy 21 additional cytogenetic abnormalities were seen in 4 patients. Two children had trisomy 8. One child had deletion of 11 chromosomes and one had translocation between 8 and 21 chromosomes. Results: All 7 children were administered intensive chemotherapy with curative intent after informed parental consent. All 7 children achieved complete remission. Four out of 7 children had complications related to severe neutropenia. Conclusion: All patients of DS with AML should be offered chemotherapy with curative intent. Endeavour should be to give less aggressive chemotherapy protocol to bring down treatment related mortality.

Daratumumab plus carfilzomib: An optimistic approach in relapsed/refractory multiple myeloma AP Dubey, Sameer Khatri, Sachin Maggo, Nilabh K Singh, Durgesh Sharma Indian Journal of Medical and Paediatric Oncology 2020 41(6):846-849 Background: Although with the introduction of novel agents, clinical outcomes have significantly improved in patients of multiple myeloma (MM); however, nearly all relapse, requiring subsequent treatment. Patients who have been heavily treated for relapsed/refractory MM (RRMM) have limited options and poor survival outcomes. Carfilzomib plus daratumumab combination have been evaluated in a phase 1b study in patients of RRMM progressing after 1–3 lines of therapies including bortezomib and an immune-modulatory drug. However, data are lacking evaluating the efficacy of this combination in RRMM patients who have progressed or have suboptimal response on either of these drugs (carfilzomib or daratumumab). Methods: Prospective analysis of data of 19 RRMM patients who progressed after multiple lines of therapy (including bortezomib and lenalidomide/pomalidomide) and had suboptimal response/stable/progressive disease after receiving carfilzomib or daratumumab based combination as last therapy. All patients received combination of carfilzomib plus daratumumab along with dexamethasone (DKd) after prior consent. Daratumumab (16 mg/kg IV) was administered weekly (days 1, 8, 15, and 22) during cycles 1 and 2, every 2 weeks (days 1 and 15) during cycles 3–6, and every 4 weeks thereafter. Carfilzomib was administered weekly on days 1, 8, and 15 of each 28-day cycle. Patients received an initial carfilzomib dose of 20 mg/m2 on day 1,2; 27 mg/m2 on day 8, 9, 15, 16 of cycle 1, which increased to 70 mg/m2 on day 1, 8, 15 from cycle 2 onwards if deemed tolerable. Dexamethasone was given as fixed-dose of 40 mg weekly. Results: Eighteen of 19 patients (including 3 high risk cytogenetics) to DKd (CR-4, very good partial response-10, partial response-02). After median follow-up of 16 months, progression-free survival (PFS) was 95%. Median PFS was not reached. Three patients who were transplant eligible received high-dose chemotherapy followed by autologous stem-cell transplantation and achieved minimal residual disease negativity. The most frequent all grade side effects were hematological, which included neutropenia 30%, anemia 70%, and thrombocytopenia 42%. Most frequent non hematological side effects were nausea 40%, vomiting, cough, respiratory tract infections, asthenia, and loss of appetite. Conclusion: Carfilzomib plus daratumumab based combination in RRMM patients has shown promising results in phase Ib study, where patients with prior exposure to either of these drugs were excluded. Our data show similar or better response of this combination in patients who had progressive disease/stable disease/minimal response to either of carfilzomib or daratumumab. This combination can be a better option in heavily treated RRMM (with prior exposure to either of carfilzomib or daratumumab) producing deeper and durable responses. A larger study may be required to prove this benefit.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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